The Department of Health and Human Services (HHS) and the Centers for Disease Control and Prevention (CDC) convened a meeting of the Advisory Committee on Childhood Lead Poisoning Prevention (ACCLPP). The proceedings were held on March 9-10, 2004 at the Admiral Fell Inn in Baltimore, Maryland.
Dr. Carla Campbell, the ACCLPP Chair, called the meeting to order at 8:47 a.m. on March 9, 2004. She welcomed the attendees to the proceedings and opened the floor for introductions. The following individuals were present for the deliberations.
ACCLPP
Members Designated
Federal Official ACCLPP Ex-Officio/Liaison Members |
CDC
Representatives Presenters and Guests |
Dr. Brown provided a status report on projects LPPB initiated or completed since the previous ACCLPP meeting. One, a Window Symposium was convened in November 2003 with a multi-disciplinary panel of ~40 experts to discuss the cost, energy and housing benefits, and health effects related to window replacement. The symposium also focused on the need to quantify energy savings for public health departments and to estimate and demonstrate property values. Participants were from the health, energy, construction, rental property and public housing fields and represented the decision analysis, economics, public health, clinical medicine and policy development disciplines. The participants were asked to specifically focus on the following questions during the deliberations.
The symposium participants raised several important points during the
discussion. Window replacement can prevent or reduce a child’s BLL and
also plays a role in asthma. Leaky, poorly maintained or improperly
installed windows can cause moisture and may lead to mold-related asthma
triggers. Windows serve as high-risk surfaces for childhood lead
poisoning because window sills and a young child’s mouth are
approximately at the same level and window troughs are highly leaded.
Substantial evidence has been collected demonstrating that window
replacement successfully reduces lead contamination.
For example, an evaluation of the U.S. Department of Housing and Urban
Development (HUD) Lead Hazard Control Grant Program was published in
1999 and showed that dust lead levels (DLLs) on window sills and troughs
significantly declined after replacement. Follow-up of the same houses
until the present showed that the decrease in DLLs was persistent over
time. No evidence has been collected demonstrating that DLLs in window
sills or troughs substantially increased since window replacement.
However, the impact of window replacement on BLLs and other health
conditions is less clear and more difficult to capture, particularly the
relationship among moisture, mold and asthma. Mold acts as a trigger for
persons with asthma, but the role of exposure to mold in causing asthma
in children is uncertain.
The symposium participants reached the following conclusions. Targeted
window replacement in low-income homes that makes housing more
energy-efficient and affordable is worthy of government support and
incentives. Successful strategies include using tax incentives, blending
existing federal funding, involving manufacturers and retailers in
educational activities, and engaging the insurance industry. Window
replacement can satisfy historic preservation concerns if these issues
are identified early in the process. To advance this activity, LPPB and
the National Center for Healthy Housing will jointly develop a white
paper to describe the Window Symposium outcomes and outline responses of
the expert panel to the questions. The white paper will serve as a
reference document for health department and housing personnel who have
an interest in pursuing window replacement.
LPPB will create an easy-to-read and short companion document to the
white paper and will also develop a decision tool to assist contractors
and others in determining whether window replacement is cost-efficient
for a particular home. LPPB will design activities to address barriers
that were identified by the participants. In particular, the U.S.
weatherization program is well accepted by property owners of low-income
units and other types of housing. However, consideration should be given
to justifying the benefits of window replacement in an effort to raise
the $2,500 cap per unit for weatherization activities. LPPB was pleased
to convene a successful forum that allowed multi-disciplinary experts
and representatives of disparate communities collectively address
housing and health issues.
Two, CDC and HUD will jointly issue a letter to health and housing
departments to confirm the authority of these agencies to share
addresses where lead-poisoned children currently live or addresses where
a series of lead-poisoned children lived in the past. The letter will
contain the following language. The Privacy Rule authorizes local
entities to release the information because CDC, HUD and the U.S.
Environmental Protection Agency (EPA) are authorized by statute to
conduct lead poisoning prevention activities. Release of the information
is consistent with the missions and capabilities of the agencies and
addresses the public health problem of lead poisoning. Programs may
disclose to the Office of Healthy Housing and Lead Hazard Control,
without parental authorization, the addresses of housing units that have
a history of lead-based paint hazards or children with elevated BLLs (EBLLs).
HUD will use the data to determine whether these properties are in
compliance with the federal Lead Disclosure Rule.
EPA, HUD, the Department of Justice and local health programs have
completed 34 enforcement settlements related to the failure of property
owners to adhere to the disclosure rule. In these cases, large property
owners did not inform tenants of potential lead-based paint hazards. To
date, $561,000 in penalties has been collected and commitments were
given to test and abate lead-based hazards in >166,000 high-risk rental
units. An additional $421,750 has been made available to fund a series
of projects, such as the purchase of portable blood lead testing
devices, provision of lead hazard abatement training, and implementation
of outreach programs.
Three, LPPB’s recent research and surveillance activities include the
publication of several articles in the Morbidity and Mortality Weekly
Report (MMWR). Ayurveda is a traditional system of medicine primarily
practiced in India and South Asian countries; minerals, herbs, animal
products or any combination of the three are used. LPPB’s MMWR article
on this issue focused on lead poisoning in adults associated with the
use of ayurvedic medications. A case was reported from New Hampshire
with a BLL of 81 µg/dL. An analysis of the patient’s medications showed
lead contents of 12,000 and 17,000 ppm. In addition to New Hampshire,
the investigation led to the identification of 12 other ayurveda cases
with exceptionally high BLLs in California, Massachusetts, New York and
Texas. LPPB was particularly concerned because some of the highly leaded
medications were being used to treat infertility in women. An ayurveda
health alert will be released in the next two months.
A lead screening study was conducted among prenatal patients in two
low-income clinics in Monterey County, California along the U.S./Mexico
Border. Of 214 women tested, all with EBLLs were seen in one clinic, 27
had BLLs >10 µg/dL and 8 had BLLs >20 µg/dL. The women represented 13%
of the prenatal population screened at the clinic and most were from
Oaxaca, Mexico. Dried grasshoppers or “chapulines” with lead levels of
47,000 ppm were among the potential foods identified as sources of the
EBLLs.
Four, LPPB is using geographic information systems (GIS) technology for
program planning and evaluation of a study in Cleveland. The project
will combine tax assessor, blood lead screening and Medicaid data to
identify under-served areas of the city. The goal of the study is to
present data in a meaningful, useful, simple and quick format to best
serve the needs of pediatric healthcare providers. LPPB is preparing a
manual to describe common data errors that prevent geocoding as well as
techniques to avoid these errors. LPPB will also post GIS 2000 census
data on its web site to allow childhood lead poisoning prevention
programs (CLPPPs) to quickly collect census data on old housing,
poverty, rental property and other issues.
LPPB used GIS to detect an unexpected number of EBLLs around the
Charleston, South Carolina Naval Yard. This area did not have a large
amount of old housing and would not have been routinely tested, but lead
paint dust was distributed in local neighborhoods from shipyard work and
by workers who brought paint home for residential use. LPPB is using GIS
in conjunction with the Washington, DC health department to evaluate the
impact of recent changes in water chemistry on BLLs of resident
children.
Five, LPPB and CDC’s other communicable disease programs are adopting
the National Electronic Disease Surveillance System (NEDSS). State
health departments will use the electronic and laboratory-based
reporting system to obtain data on STDs, tuberculosis, bacterial
meningitis and other diseases from laboratories and forward the
information to CDC. NEDSS will also maintain addresses, patient
demographics and disease types. Release 1 of NEDSS is expected to be
issued by the end of 2004, but lead will not be included in this
version. However, Nebraska and South Carolina are currently deploying
NEDSS to transmit data to CDC on vaccine preventable conditions,
hepatitis and other diseases. To date, 29 other states have also
expressed an interest in implementing NEDSS by the end of 2004. NEDSS
will provide LPPB with a wealth of information and capacity to identify
risk factors at geographic and population levels.
Six, LPPB is in the process of developing a lead program area module
(PAM) that will be the first environmental health condition included in
the NEDSS-based system. LPPB completed the prioritization of PAM
features by convening meetings to obtain input from state and local
partners that use other computerized database systems to manage cases.
Joint application development sessions were also held with state and
local program staff to discuss development of the lead PAM and
usefulness of the system at state and local levels. Over the next 18
months, LPPB expects to migrate data from the Systematic Tracking of
Elevated Lead Levels and Remediation system into the lead PAM.
Seven, LPPB is currently focusing on several electronic laboratory
reporting issues. Most notably, efforts are being made for health
departments to agree on using HL7 and other conventional techniques in
submitting data to NEDSS. The overarching goal of these activities is to
develop a rapid, common and less labor-intensive electronic laboratory
reporting system.
Eight, LPPB is designing health education initiatives due to survey
results that show 17 of 37 funded states have no laws to enforce
remediation of homes with children who have EBLLs. LPPB is partnering
with the Alliance for Healthy Homes (AHH) and the National Conference of
State Legislators to compile health education information for state
legislators. The materials will contain specific data for each state,
including the total number and percentage of pre-1950 housing units; the
total number of children <72 months of age and those in poverty; the
total number of children tested in 2001 and those with confirmed BLLs
>10 µg/dL; requirements for dust clearance testing; the proportion of
lead paint abatement completed or ordered by the health department; and
the existence of a local or state ordinance requiring home inspection
and repair of lead hazards in the home of a child with an EBLL. LPPB
acknowledges the importance of health education projects because
capacity to enforce remediation in states with a significant amount of
high-risk housing and large populations of lead-poisoned children will
be critical in reaching Healthy People 2010 goals.
Nine, LPPB is engaging in efforts to improve its vocabulary because “EBLLs,”
“undue lead absorption,” “lead poisoned” and similar terms may not be
understood by parents and other care givers of children with EBLLs. LPPB
will convene a series of focus groups to improve and obtain reactions to
the current lead poisoning terminology. Input from the focus groups will
be used as a basis in developing a new lead vocabulary that will be
meaningful to LPPB’s target audience. One white, one Hispanic and two
black focus groups with non-college educated mothers or female care
givers of children <6 years of age who have an annual income <$35,000
will be conducted by telephone. Each of the U.S. regions in urban areas
will be represented.
Ten, LPPB will release a videotape in May 2004 in an effort to improve
blood lead sampling techniques. The videotape will illustrate errors
that can cause contamination of capillary blood lead samples and
preventive measures.
Eleven, LPPB taught a five-day classroom course and convened a five-day
activity in the field to engage individuals in program evaluation.
Harvard School of Public Health students collaborated with LPPB project
officers to learn more about program evaluation, review the public
health process, obtain practical skills and include this experience on
resumes. The project officers and students conducted several field
activities throughout the country.
In Alabama, case management was evaluated to determine the extent to
which protocols are followed and whether case management contributes to
decreased BLLs in referred children. In California, education of public
health nurses who are not currently involved in lead was assessed to
determine if nurses have time to inform families about lead poisoning
prevention during home visits and whether changes in practice decreased
lead exposure in high-risk families. Other program evaluations included
a screening and outreach program by a community-based organization (CBO)
in Connecticut; new abatement referral procedures in Detroit; case
management in Indiana; an evaluation template for media campaigns in New
York City; a housing-oriented primary prevention project in North
Carolina; and the “Lead-Safe Baby Program” in Philadelphia. Over the
next six to eight months, project officers will begin implementing
project evaluations the students wrote in methodology papers. The course
was extremely beneficial to project officers, students and lead
programs.
Dr. Hoffman inquired about the role of LPPB’s GIS projects in improving
screening of all Medicaid children. He also asked whether NEDSS will
present confidentiality problems since the system will reveal the
specific address of a child with lead poisoning, tuberculosis or another
condition. Dr. Brown replied that LPPB will use GIS in the Cleveland
study to pinpoint specific locations in communities where Medicaid
children have or have not been screened. The initiative will be designed
to result in active outreach. To the second question, she clarified that
NEDSS will not raise confidentiality issues because state health
departments are required to report these diseases. Data will be
submitted to CDC through NEDSS with no identifiers.
Mr. Rob Henry,
the Program Services Section Team Leader, reported that LPPB funded 42
CLPPPS in 37 states and five cities in FY’03 as a step in reaching the
Healthy People 2010 goal of eliminating childhood lead poisoning. LPPB
also convened workgroups with internal staff and federal, state and
local partners to discuss strategies to ensure success in this area. In
response to this input, LPPB changed several program requirements in the
cooperative agreement for state and local programs. Funding is now
targeted to areas in the country with populations at highest risk. The
five state CLPPPs with the highest number of children at risk for EBLLs
were previously asked to address primary prevention, but all CLPPPs are
now required to focus on this issue. LPPB and CLPPPs will strengthen
collaboration to support protective policies in 17 states that have no
laws to protect children with EBLLs.
The most significant change in the cooperative agreement is the
requirement for CLPPPs to develop lead poisoning elimination plans. In
general, CLPPPs will be expected to strengthen capacity in identifying
and reaching vulnerable populations; target resources to high-risk
children even in states with universal screening; place heavy emphasis
on Medicaid matching; develop strategies to link BLL data to information
on children who are at high risk for other conditions; design primary
prevention activities; and establish policies to address and protect
children.
In particular, LPPB established several guiding principles to assist
CLPPPs in creating the plans. “Elimination” should be defined at the
state level due to differences in populations and problems by
neighborhood, city, jurisdiction and other geographic areas of the
state. Participation by leadership in strategic planning activities
should be demonstrated and a wide range of stakeholders should be
engaged as well, including EPA, HUD, public health departments, Medicaid
and environmental regulatory agencies. Data should be compiled to
clearly describe the problem. Existing policies or enforcement actions
that currently protect children and assist in lead poisoning prevention
should be thoroughly reviewed.
Resources for strategic plans should be identified and matched to a work
plan with measurable goals and objectives. A strong evaluation component
that can be revised and improved over time should be incorporated into
strategic plans. In terms of the time-line, CLPPPs are required to
submit non-competing continuation applications and draft elimination
plans to CDC on March 19, 2004; final elimination plans are due on June
30, 2004. LPPB will use the April 2004 CDC Partners Conference as an
opportunity to provide technical assistance to CLPPPs in finalizing the
elimination plans. Implementation and evaluation of the plans will
continue throughout 2005 and the program announcement will be
re-competed in 2006.
Throughout the strategic planning process, LPPB will remain actively
involved with CLPPPs; ensure that project officers are regularly
informed; and provide technical and scientific assistance through site
visits, conference calls, training, conferences, meetings, special
projects and evaluation. These activities will identify staff who can
assist CLPPPs in resolving problems and will also help CLPPPs to improve
surveillance activities and develop work plan goals and objectives. LPPB
has released a request for proposals to redesign its national lead
training center to be more dynamic, thorough and specialized. The
project will provide general and focused training to CLPPP personnel
with special skills, including case managers, new program managers and
epidemiologists.
Dr. Keyvan-Larijani suggested that LPPB consider a different approach in
the strategic elimination plans. For example, resources could be
initially allocated to high-risk jurisdictions only to provide an
opportunity for these CLPPPs to reach the same BLLs as other areas in
the state. All CLPPPs in the state could then collectively take actions
toward achieving elimination. Dr. Brown expressed concern with this
suggestion because lead poisoning elimination requires considerable
infrastructure and support. If resources are only targeted to high-risk
areas, infrastructures would most likely need to be reestablished in
low-prevalence jurisdictions in the future.
Dr. Hoffman inquired about the ability of the 13 non-funded states to
successfully compete in the 2006 program announcement with grantees that
have maintained stronger infrastructures and developed elimination
plans. Mr. Henry confirmed that LPPB is currently considering strategies
to closely collaborate with non-funded states, particularly those that
have not been funded in recent history and for which there are no data
available to describe childhood lead poisoning problems. LPPB has also
discussed the possibility of developing a passive surveillance system
for those states that have low prevalence. Dr. Stephens conveyed that a
progressive approach may be more practical in which cities, states and
counties would first reduce BLLs and then focus on elimination. He also
raised the possibility of LPPB creating and distributing a legislator
handbook that describes relevant laws and policies for lead poisoning
elimination. To assist in this effort, ACCLPP could identify and suggest
laws for each state.
Mr. Henry reported that LPPB is currently collaborating with AHH to
collect examples of primary prevention activities from CLPPPs and
publish these models in a manual. The section of the manual that will be
devoted to policy and enforcement could perhaps be designed as a
stand-alone document for legislators. Dr. Campbell added that a wealth
of information currently exists for state legislators to access, such as
model laws on the National Conference of State Legislators web site.
Dr. Rogan noted that LPPB’s activities actually target the “frequency”
of EBLLs among screened children rather than “prevalence” of EBLLs. He
also pointed out that some of the strategic activities LPPB will
evaluate do not have supporting research. He asked if any of the
initiatives can be designed to produce information that can be
generalized to other settings. Dr. Brown clarified that some of LPPB’s
activities are research projects, while others are program evaluation
projects. For example, some of LPPB’s evaluation projects are randomized
control trials, while the Chicago High Intensity Targeted Screening
(HITS) program was intended to obtain prevalence data on EBLLs using a
clustered stratified sample. LPPB and EPA have been discussing the
feasibility of conducting a similar project in Mississippi. However, Dr.
Brown did not see the purpose of attempting to obtain prevalence rates
from Massachusetts and other well-established lead programs.
Dr. Binns suggested other information for LPPB to include in the state
legislator report cards, such as whether the lead program is a CDC
grantee, the number of years of funding received, and contact
information for the state environmental leader. She also advised LPPB to
begin outreaching to and partnering with unfunded states by conducting
small studies on prevalence rates of EBLLs, housing descriptions and
similar issues. Dr. Brown noted on the one hand, LPPB has a strong
interest in analyzing a surveillance system in a state that has either
achieved elimination or low prevalence. On the other hand, LPPB has
received level funding for the past eight years and will not cut program
services to conduct these types of special projects.
Dr. Lynn urged LPPB to carefully consider the presentation of
information and tone of messages that will be conveyed in the state
legislator report cards. Similar to federal agencies, states also have
considerable budget constraints and may not view lead issues as a
priority compared to other competing activities. Moreover, many states
may be reluctant to accept guidance from federal agencies. Dr. Brown
confirmed that LPPB will consider these important comments and structure
the report cards to illustrate the resource intensity of taking
different approaches. Dr. Hoffman announced that health institutes are
privately funded organizations for legislators to access health data in
one location. The health institutes provide legislators with vital
statistics, surveillance data, Medicaid costs and similar information.
He encouraged LPPB to collaborate with these groups in disseminating the
state legislator report cards.
High Intensity Screening in Chicago's Strategic Elimination Plan
Ms. Anne Evens, the Chicago Department of Public Health Lead Poisoning
Prevention Program Director, described methods to assess BLLs and
screening of high-risk children in Chicago. Based on 2001 data, Chicago
had 308,415 children <6 years of age. Of those, 28% of children 1 year
of age and 51% of children 2 years of age had received a BLL test; 12%
of those tested had BLLs >10 µg/dL; and 45% of children born in Chicago
each year are enrolled in Medicaid. Chicago has 660,000 pre-1950 housing
units and 88,000 housing units that are hazardous to children. One in
three children tested has an EBLL in some Chicago neighborhoods.
However, childhood lead poisoning has been eliminated as a public health
problem in 14 of 77 jurisdictions in Chicago.
The Chicago CLPPP is a multifaceted program with 72 staff who focus on
surveillance, blood lead screening, medical case management,
environmental inspections and enforcement, and the HUD abatement grant.
The Chicago CLPPP incorporated four major strategies in its elimination
plan. Additional funding is leveraged for abatements related to window
replacement in a lead-safe manner, paint stabilization and other lead
hazard interventions. Efforts are currently underway to enforce laws at
federal, state and local levels to increase the interest of property
owners in making properties lead safe and to provide financial
incentives. Projects are designed to increase identification of young
children with EBLLs and improve screening, particularly in high-risk
neighborhoods. An evaluation component is incorporated into the plan to
measure progress toward elimination.
The Chicago CLPPP implemented the first HITS in 2001 to determine the
prevalence of children <6 years with EBLLs and to evaluate screening
efforts. The activity was later expanded to collaborate with the
immunization program and CBOs to assess other health indicators, to
increase awareness of EBLLs in communities, and to improve screening of
children enrolled in Medicaid. HITS has been conducted three times in
six communities. These communities account for nearly 33% of BLLs >20
µg/dL in the city according to city surveillance data. The fourth HITS
will be launched on April 3, 2004. The effectiveness of screening widely
varies by neighborhood in Chicago.
Surveillance data shows a range of children < 6 years screened as low as
26% to a high of 47% in high-risk communities.
The HITS components include development of a protocol, review by an
Institutional Review Board, staff training, blood lead testing, measles
and rubella titers, informed consent, health data surveys, cleaning and
hepa vacuum training, medical case management, home inspections,
abatement, data analysis, evaluation, and recommendations for CLPPP
screening initiatives. On the one hand, HITS validated prevalence
estimates; gathered baseline data for sentinel surveillance of high-risk
neighborhoods; identified 27% of children with BLLs >10 µg/dL who would
have been missed by routine screening efforts; resulted in new and
improved screening efforts; played a role in enrolling children into
primary care and increasing measles and rubella immunization rates to
85%-90%; raised community awareness of EBLLs; strengthened knowledge of
other health indicators; and served as an activity that was accepted by
community groups and residents. The most significant outcome from HITS
activities has been that 61% of children tested in these high-risk
neighborhoods had not been previously screened. Of those, 70% were
enrolled in Medicaid.
On the other hand, HITS is complex to manage, requires challenging work
hours, and raises safety and security concerns. Moreover, the ability to
generalize HITS to other settings is questionable. HITS is also costly
and will be impractical for a citywide project. On average, $300 was
required to screen each child, $320,840 was needed to implement the
first three HITS, and $52 per child was allocated for fixed outreach.
These costs were found to be much higher than those in pediatric offices
or public clinics.
After gathering HITS data, the Chicago CLPPP focused on reasons why 61%
of children tested had not been previously screened for blood lead. The
analysis showed that children were not presenting for well child visits
and physicians were failing to screen during well child visits. The
Chicago CLPPP’s review of Medicaid billing records showed that 25%-33%
of children <6 years of age had not had a well child visit in the
previous 12 months. Since adherence to well child visits was found to be
better among children 0-12 months of age, the Chicago CLPPP is
partnering with the immunization program to increase well child visits
among children 13-24 months of age.
The Chicago CLPPP also collaborated with the immunization program to
audit >20,000 physician charts of lead screening and immunization rates
in >300 clinical settings. Citywide results showed that 67% of providers
in high-risk neighborhoods in Chicago are testing children according to
the guidelines. However, physicians still cited several barriers to
testing, including insufficient staff to draw blood on site, the cost to
parents for off-site testing, the lack of free blood lead testing
throughout the state, problems associated with drawing blood from young
children, and insufficient time to test during well child visits.
Surprisingly, providers did not perceive “lead poisoning is no longer a
problem” as a barrier to testing.
Overall, HITS was found to be an effective educational tool because most
providers have no lead poisoning data on their patients. As a result,
the Chicago CLPPP implemented several activities that have resulted in
improved screening rates. Recommendations are made and follow-up
assessments are conducted for providers with the lowest screening rates.
Healthcare providers are educated through conferences, data mailings and
web-based classes with continuing medical education credits. Pediatric
and family planning medical residents are invited to participate in the
Chicago CLPPP for one day and conduct a site visit with an inspector.
Charts of blood lead testing, immunization rates and well child care
visits will continue to be reviewed in providers' offices. Feedback and
recommendations for improvement will be given based on these
assessments. Educational activities will be specifically targeted to
certified nursing assistants and medical technicians as well. The
Chicago CLPPP also designed initiatives for parents to increase well
child visits, including educational materials distributed through birth
certificate inserts, mailings and community meetings; targeted outreach
to untested children 13-24 months of age enrolled in Medicaid; free
blood lead testing at Women, Infant and Children sites, day care centers
and churches; and incentives for testing in certain settings.
Dr. Hoffman remarked that due to seasonality, April 3, 2004 may not be
the best date to launch the fourth HITS. Children with EBLLs may not be
identified at this time of the year and the overall EBLL rate may be
affected. He noted that June-August are the optimal months to obtain
EBLLs because windows are more likely to be open and children
participate in more outdoor activities during this time of year. Dr.
Hoffman also raised the possibility of the Chicago CLPPP using the
second dose of measles, mumps, rubella immunization to measure adherence
to well child visits since older children receive this dose.
Ms. Evens conveyed that the Chicago CLPPP selected April for the fourth
HITS since children will be home for spring break. Based on the earlier
HITS, late summer and early fall were not found to be optimal times due
to a high refusal rate. Many children are tested during these seasons
and most parents are reluctant to have their children undergo another
blood draw. However, the Chicago CLPPP will be mindful of seasonality.
Dr. Piomelli explained that blood drawn from a finger stick and placed
onto filter paper is a successful method to test children and can be
used by providers. This technique may address the issue of insufficient
staff to draw blood onsite. He emphasized the need for CDC to educate
providers in using this procedure. Dr. Piomelli also underscored the
importance of the members collectively reviewing and commenting on the
HITS results because the study is pertinent, relevant and germane to
ACCLPP’s function. Dr. Campbell confirmed that ACCLPP will discuss
outstanding issues related to HITS during the “unfinished business”
agenda item on the following day.
Lead in Drinking Water
Dr. Victoria
Binetta of EPA described recent events related to water quality in the
District of Columbia (DC). The Corps of Engineers owns and operates the
Washington Aqueduct and uses the treatment plant to draw and treat water
from the Potomac River and distribute treated water to ~1 million DC and
northern Virginia residents through the Water and Sewer Authority (WASA).
EPA regulates drinking water quality under the Safe Drinking Water Act
and also manages lead in drinking water under the Lead and Copper Rule.
The maximum contaminant level (MCL) is the maximum allowable
concentration of a contaminant in treated water. However, MCLs and MCL
goals frequently differ because MCLs are determined on the basis of
feasibility and cost of treatment, while MCL goals are established by
health-based levels. EPA’s MCL for lead was 50 ppb in 1975, but the MCL
goal has been revised since that time.
Lead in water is generally caused by plumbing systems in buildings, but
is rarely a problem in the water source or treated water. As a result,
EPA regulates water quality for lead differently than for other
contaminants. Most notably, action levels rather than MCLs have been
established for lead and treatment technology is used to regulate lead.
Water suppliers must adjust water chemistry to make water as
non-corrosive as possible and ensure that lead is not leached from lead
pipes or other lead fixtures. Despite the differences for lead, water
suppliers must still achieve the objectives of other water quality
regulations. Utility companies must monitor water from taps that is
distributed in individual homes to ensure corrosion is controlled and
lead in residential faucets is minimized. For purposes of monitoring, a
pool of homes are selected to represent “worst-case” scenarios. If
lead-bearing or lead service lines connect a house to a water main
within a city, 50% of the sample must be homes with lead service lines.
Sample homes are also selected based on vintage, such as construction
during a time when lead sodder was more commonly used.
In monitoring homes, water suppliers are expected to achieve a
regulatory threshold and must not exceed the action level for lead of 15
ppb. For example, 90% of homes in the sample may have lead levels of <15
ppb, but no more than 10% can have lead levels of >15 ppb. Utility
companies have different monitoring schedules based on the size of the
water system; however, monitoring is primarily conducted by homeowners
who obtain and bottle water samples for pick-up and analysis by the
utility company. WASA offered a $25 incentive for homeowners to provide
samples, but many individuals volunteered to participate.
Based on early sampling results, the worst-case homes showed a mean
level of 37 ppb and triggered the development of a corrosion control
plan. Extensive studies were also conducted to determine optimal
corrosion control strategies for DC, such as controlling PH and alkaline
levels or adding a corrosion inhibitor. EPA conditionally approved DC’s
corrosion control plan, but sampling results from the worst-case homes
in June 2002 showed a dramatic increase in lead levels from 8-75 ppb.
The cause for the change in water chemistry is still unknown at this
point.
DC took several actions to comply with EPA regulatory requirements after
the action level of 15 ppb was exceeded. Corrosion control treatment was
reviewed and optimized and tap water monitoring was intensified.
Brochures, public service announcements and targeted outreach
initiatives to pregnant women, children and other high-risk populations
were used to educate customers about lead health effects, the occurrence
of lead in drinking water and actions to reduce lead exposure. Removal
of lines that connect water mains to homes was initiated since the
utility company had lead service lines and already optimized corrosion
control. To date, <7% of 23,000 lead service lines have been replaced in
DC, but utility companies are not required to replace pipes if water
samples contain <15 ppb of lead. The monitoring schedule was increased
from sampling 50 worst-case homes per year to 100 every six months.
Of every six single-family residences in DC, ~1 is served by a lead
service line. WASA began taking one-liter water samples from lead
service lines to identify those of highest priority in which lead
leached from immediate plumbing fixtures nearest to faucets. WASA saw
very high lead levels and an extraordinary amount of leaching based on
2003 sampling results from water in lead service lines. From
March-September 2003, WASA tested 4,613 lead service lines and
determined that only 27% of samples were below the action level of 15
ppb, while 18% were >100 ppb. The previous educational campaigns and
other public outreach activities were not effective because the
seriousness of the problem was not known at that time and had not been
conveyed. Moreover, press coverage heightened public awareness.
Follow-up actions were taken in response to the more recent information
on changes in water chemistry. DC, EPA, WASA and the Washington Aqueduct
reached consensus on issuing new guidance. Consumers were generally
advised to flush taps for 60 seconds after an inactive period, draw cold
water for drinking and cooking, and clean faucet strainers once per
month. WASA surveyed historical housing records to identify lead service
lines, but admits a 10% level of uncertainty in detecting all lines.
Consumers who may have lead service lines were specifically advised to
flush taps for ten minutes after significant water use before drawing
water for drinking or cooking. Information was mailed to residents in
these households to encourage water sampling. Disinfection practices
were revised to reduce compounds in the water supply and better control
biofilm in distribution pipes. Water meters were replaced in 18,000
homes in 2002-2003.
An advisory was issued on February 26, 2003 recommending that pregnant
women, nursing mothers or children <6 years of age in homes with actual
or potential lead service lines not drink unfiltered tap water or use
the water to prepare formula or concentrated juices. The DC Department
of Health (DOH) is offering free BLL testing for residents in homes with
actual or potential lead service lines; conducting follow-up with home
visits and case management of target populations; and collaborating with
CDC to assess BLLs throughout DC. EPA expects WASA to accelerate the
testing schedule and lead service line replacement. WASA will provide
filters or an alternate water source for highest-risk populations.
A preliminary report will soon be completed identifying the next series
of studies that need to be conducted. EPA Headquarters and regional
offices as well as state regulatory agencies were contacted to determine
if high lead levels in water had been seen in other parts of the
country. To date, similar water quality problems have not been reported
outside the DC area, but EPA will still conduct a national compliance
review to ensure the action level is not exceeded in other states. For
example, all water samples taken in Falls Church, Virginia were found to
be <4 ppb, but lead levels in water above the action level were detected
in 50% of samples from Arlington, Virginia. Both Falls Church and
Arlington are conducting additional sampling in schools and households.
EPA will review its regulatory requirements for public education since
the outreach and guidance were not successful in DC. As a result, more
urgent messages on reducing lead exposure will be communicated to the
public.
Dr. Brown confirmed that CDC is closely partnering with the DC and
Arlington, Virginia health departments to respond and continue to
monitor the lead in drinking water emergency by reviewing existing data
and assisting in identifying new data. CDC is also supporting the DC
lead advisory that recommended pregnant women and children <6 years of
age not drink water from houses with known lead header pipes or service
lines unless the water was filtered or bottled. The Brita Water Company
supported the lead advisory as well by donating 10,000 water filters for
distribution to DC residents.
Dr. Brown also reported that CDC is collaborating with the DC DOH to
match water and BLL tests from 1998. Pregnant women, children <6 years
of age and all residents in homes with lead levels in water of 300 ppb
are being actively targeted for lead testing. However, any individual
who requests a BLL test in an emergency room or other setting will
receive the test. Dr. Binns was concerned that the lead advisory did not
specifically mention “women of child-bearing age” as a population of
concern. She encouraged EPA and the DC DOH to partner with the media to
effectively communicate health risks from lead to adults.
Dr. Campbell reported that the latest version of the document was distributed to ACCLPP in December 2003 and revised based on comments from the members. At the time of the meeting, the document was to be submitted soon to CDC for clearance. She thanked the members for their comments, diligence and dedication in finalizing the document. By the next ACCLPP meeting, the primary prevention document will have been published as a stand-alone CDC document and distributed to grantees for guidance.
Demonstration of a Web-Based Housing Registry
Ms. Patricia McLaine is the ACCLPP liaison for the National Center for
Healthy Housing. She announced that “LeadSafeHomes.info” (LSH) is a
web-based housing registry of property information for Baltimore,
Boston and Chicago. Several city agencies, EPA regional offices and
community groups were instrumental in developing the HUD-funded
activity. The project period was extended for one year to create the
web site; the initiative is expected to be launched in March 2004. The
LSH web site will provide public access to the lead status of homes
and lead educational materials. Specific information will be displayed
for each city, including a home page, property report, community
report and contacts for additional information.
The property report will illustrate age and risk of housing, list
recommendations, describe the lead inspection history, outline address
and blood lead summaries, and provide links to additional information
of interest. The community report will contain a color-coded map to
illustrate violation rates and BLLs by census tract, areas with
insufficient data, and high-risk block groups within census tracts.
For example, no census tracts in Boston had 12% of BLLs >10 µg/dL. The
LSH web site will contain an interactive matcher to allow users to
scan the entire city for properties that were identified, inspected
and de-leaded. Topics of special interests will be categorized by
groups, including landlords, parents, healthcare providers, city and
state officials, community organizations and tenants. For example, the
landlord page will provide information on lead contractors.
Each web page will be tailored for the respective city. For example,
distinct symbols will be displayed on the Baltimore property report to
illustrate the status in the Maryland lead rental registry program,
such as receipt of a full or provisional lead-free certificate,
compliance with a full or modified risk reduction standard, or program
registry only. City agencies, rental registries, abatement data and
GIS mapping files were used as data sources for the LSH web site.
Overall, the web site will serve as a powerful tool and allow data to
be reviewed differently for neighborhoods, block group areas and
specific properties.
Dr. Lynn mentioned that users may interpret the “check mark” symbol to
mean all aspects of the home are in compliance and concern is not
needed. However, she pointed out that a de-leaded home is not
necessarily a permanent solution. Ms. Barbara Conrad, of the Maryland
Department of the Environment, explained that the LSH web site will
have a number of potential uses. The housing market may be impacted
since landlords and other property owners may be more inclined to meet
lead risk reduction standards in units. Prospective homeowners and
tenants will have a solid source of information to aid in the
decision-making process about a particular property. Homeowners and
tenants who can document unsafe units may be able to strengthen court
cases against landlords. Advocacy groups for lead safe homes can more
effectively assist tenants and homeowners.
Update on National Center for Environmental Health/Agency for Toxic Substances and Disease Registry (NCEH/ATSDR) Activities
Dr. Henry Falk, the NCEH/ATSDR
Director, covered the following items in his status report. First, the
consolidation of NCEH and ATSDR was initiated in August 2003 in response
to agreement by the HHS Secretary, CDC Director, Office of Management
and Budget, Congressional committees and various external groups.
Maintaining two environmental agencies in HHS that both report to the
CDC Director/ATSDR Administrator was not found to be an efficient
process. NCEH was created as a formal CDC center in 1980 after providing
environmental health expertise in response to the Three Mile Island
accident. ATSDR was established by the Superfund legislation to
specifically address lead and other environmental health issues at
Superfund sites.
Leadership, management and administrative functions of the two agencies
were consolidated rather than fully merged because the Superfund law
still requires ATSDR to be maintained as a separate agency. However, the
consolidation is expected to promote greater coordination and
collaboration between NCEH and ATSDR. To date, administrative offices of
the agencies were realigned with a common leadership and similar
management positions were streamlined. The consolidation is expected to
be completed by the end of 2004. The consolidation will not affect CDC’s
lead activities due to strong support of and continued commitment to
LPPB by the CDC and NCEH/ATSDR Directors. Most notably, Dr. Falk was
extensively involved in CDC’s early lead studies in the 1970s,
participated in the development of the 1991 strategic plan for childhood
lead poisoning elimination, and served as the ACCLPP Executive Secretary
prior to his appointment as the ATSDR Assistant Administrator.
Second, CDC’s Futures Initiative is a broad strategic planning effort
that will have a significant impact on the agency-wide structure and
resources. Due to the 9/11 terrorist attacks, anthrax episodes and
outbreaks of monkeypox and severe acute respiratory syndrome, CDC has
received more media attention in the last two years. As a result, the
CDC Director launched the Futures Initiative to provide an opportunity
for CDC to respond to public health priorities as quickly as possible.
The Futures Initiative is designed to guide CDC's future directions in
terms of its organization as a public health agency and issues to
address. In particular, CDC will broaden its function from supporting
state and local health departments to becoming more engaged with the
general U.S. public.
The four Futures Initiative priorities are partnerships, CDC's role in
the U.S. health care system, applied research to support extramural
activities, and global health. CDC spent a considerable amount of time
gathering input on these issues from partners, stakeholders, researchers
and representatives of the health care system. NCEH/ATSDR also discussed
strategies to strengthen capacity in these areas from an environmental
health perspective. CDC will begin implementing the Futures Initiative
in January 2005 by focusing on its role in preventing disease and
protecting public health from threats. Detailed goals for these two
focus areas will be submitted to the CDC Director by the end of March
2004.
Dr. Hoffman inquired about the role of the consolidation in reducing
NCEH/ATSDR resources. Dr. Falk clarified that administrative savings
were distributed to programs. The consolidation did not place NCEH/ATSDR
resources at risk; instead, wars, tax cuts, Department of Homeland
Security activities and other competing priorities at the federal level
are the cause of budget constraints.
Dr. Banner asked if the consolidation will allow ACCLPP to become more
involved with ATSDR activities, particularly lead issues at the Tar
Creek Superfund site. Dr. Falk explained that ACCLPP’s focus depends on
its charter. For example, ACCLPP is charged with addressing broad lead
issues at the national level rather than those for specific sites. In
lieu of changing the charter, he suggested that updates on lead issues
at Superfund or mining sites be provided at future ACCLPP meetings. In
terms of Tar Creek, ATSDR is currently reviewing BLL and other
environmental data gathered from the site and will submit a report of
its findings in July 2004. Dr. Falk offered to provide an update on Tar
Creek at the next ACCLPP meeting.
Dr. Ho was extremely pleased that CDC will adopt the National Institutes
of Health (NIH) model for research programs. He requested more details
on this activity. Dr. Falk replied that the research mechanism will be
launched in the next few months. Efforts are currently being made to
structure a substantive extramural research program throughout CDC and
leverage funds to ensure that the activity grows and flourishes in the
future. CDC will place emphasis on distinguishing between basic research
and applied research that will be needed to strengthen its programs.
Update on the Adverse Health Effects of BLLs <10 µg/dL Workgroup Report
Dr. Thomas Matte
of CDC summarized comments that were submitted for the workgroup to
consider while revising the report. Questions raised by these comments
included; whether a policy discussion should be included in the
background section, whether non-significant results should be
considered, whether original data should be analyzed, whether the
threshold discussion should be modified, whether non-peer reviewed
results should be cited; how the report should address the unexpected
outcome of the BLL relationship becoming steeper at lower levels;
whether the term “lead Poisoning” should be used; what the format and
tone of the conclusions should be; and how conclusions that can be drawn
from studies on children’s BLLs and health status are impacted by the
fact that BLLs can only be measured at certain time points. Dr. Matte
noted that minor wording changes that were suggested that did not impact
the overall conclusion, as well as suggested additional references were
not included in his presentation. Dr. Matte then reviewed changes to the
October 2003 draft workgroup report made in response to specific
comments. His presentation can be found in attachment A.
To guide the discussion on the workgroup report, Dr. Carla Campbell
asked ACCLPP to specifically consider whether the document should be
finalized and published at this point or if additional changes need to
be made. ACCLPP’s deliberations focused on the process of developing the
workgroup report and the content of the document. In terms of process,
Dr. Banner’s understanding was that the workgroup would create a product
for ACCLPP to use as a guidance document or scientific commentary;
instead, it seemed to him that a stand-alone report will be published
without ACCLPP ownership. He added that the workgroup’s decisions were
made independent of ACCLPP. Dr. Hoffman requested that a statement be
incorporated to explain whether or not ACCLPP supports the document. He
was not in favor of publishing the report as a workgroup product. Dr.
Lynn noted that the workgroup is heavily populated with non-ACCLPP
members.
With respect to content, Dr. Leighton found the document to be excellent
because the workgroup addressed extremely technical issues, thoroughly
analyzed the epidemiologic literature and clarified several complex
topics. However she suggested that the document be further edited to
shorten particular paragraphs. Dr. Towers was also impressed with the
workgroup’s thorough review of the available evidence. Dr. Piomelli
pointed out that during the previous ACCLPP meeting, the Workgroup Chair
stated “current data do not support labeling children with BLLs <10
µg/dl as lead poisoned.” However, this important comment is excluded for
the current version of the document. The purpose of the report is to
emphasize the importance of causality of BLLs <10 µg/dL. The document
may be used to make policy decisions and will serve as a critical tool
in ACCLPP advising CDC on whether to lower BLL of concern from 10 µg/DL
to 5 µg/dL. However, the does not serve as a guidance document because
clear and definite conclusions are not made.
Dr. Piomelli further noted that language is not included in the report
to emphatically state whether BLLs <10 µg/dL are harmful to children.
The conclusions should be clearly stated in bullet points. Dr. Piomelli
also stated that the workgroup report was not sufficiently skeptical
about the steeper slope of the blood lead IQ relation observed at lower
blood lead levels. He wrote a letter to ACCLPP explaining that the
Bellinger and Canfied results are due to an artifact due to
classification of children as never having BLLs above 10 when in fact
their levels may have been above 10 between measurements. He recommended
that these findings be rejected. Dr. Piomelli also asserted that the
document was not consistent with the version presented by Dr. Weitzman
at the October meeting and questioned whether Dr. Weitzman approved of
the revised version.
Dr. Matte replied that the workgroup report was modified in response to
Dr. Piomelli’s comments on misclassification of children as never having
blood lead levels above 10, but that the workgroup could not identify a
mechanism whereby the increasing slope closer to 0 could be produced by
the classification bias Dr. Piomelli described. As a result, the
workgroup’s change to the current version of the document differs from
Dr. Piomelli’s opinion. Dr. Matte also noted that Dr. Weitzman had
reviewed and approved the revisions to the workgroup document.
Dr. Banner disagreed with the workgroup’s approach of citing published
data that were not statistically valid to form an association. Inclusion
of these data may cause ACCLPP to be perceived as a non-scientific group
or the report to be viewed as an unscientific analysis or a political
document. The report will be shorter and more useful if these data are
removed. Because the current version is voluminous and vague,
conclusions about the steeper slope at lower BLLs and other solid points
made by the workgroup are minimized. The report references uncertainty
in the data, but the document would be strengthened by adding confidence
intervals to actually illustrate uncertainty. The document should also
clearly state that additional research is needed to determine whether
confounding has been fully addressed in observational and
non-experimental studies. Dr. Banner questioned whether a potential conflict of
interest exists because both the Workgroup Chair (Dr. Weitzman) and the author of the primary
study cited in the report are from the University of Rochester.
Dr. Matte and Dr. Rogan both noted that the use of non-statistically
significant findings in reviews of the literature and meta-analyses is
consistent with accepted scientific practice. Also, instead of reviewing
each individuals study in a vacuum, the workgroup took a scientific
approach by interpreting NHANES results, the Canfield study and other
relevant data as a collective body of evidence. The workgroup agrees
that the report can be enhanced by flagging significant studies or
adding “n’s” in figures to illustrate uncertainty in the data. Dr. Matte
noted Dr. Weitzman did not have a conflict of interest because of his
affiliation with the University of Rochester because he was not directly
or indirectly involved with the Canfield study. The workgroup
objectively reviewed the Canfield study and the report raised many
questions about the interpretation of these data.
Dr. Lynn recognized the workgroup’s diligent efforts in collecting,
reviewing and compiling a tremendous amount of data and addressing a
considerable number of conflicting comments from ACCLPP. She was in
favor of the document being finalized with additional editing to
condense the text and remove repetitive references to the Bellinger
letter and the Canfield study. The document may be perceived as relying
too heavily on these data sources. An editor should also clarify the
discussion on the steeper slope at lower BLLs. Dr. Lynn also suggested
that an executive summary be developed and incorporated into the report.
Dr. Binns mentioned that the report will serve as an important source
for researchers in the field. She acknowledged that the workgroup could
not make a definite conclusion about the steeper slope at lower BLLs
because sufficient data have not been gathered to demonstrate this
outcome. Her position was that the data gap is adequately expressed in
the document. Dr. Hoffman conveyed that if ACCLPP votes to approve the
workgroup report, comments should not be made to drastically change the
document.
Dr. Campbell responded to ACCLPP comments on process as follows. The <10
Workgroup used the same process as the Case Management and Primary
Prevention Workgroups. ACCLPP and the <10 Workgroup had a considerable
amount of interaction during several meetings. The workgroup prepared
and presented drafts to ACCLPP for review and comment and revised
documents based on feedback from the members. The workgroup report will
list the authors, but the document will be published as an ACCLPP
product after ACCLPP reaches consensus by a vote. The membership of the
<10 Workgroup is similar to other workgroups in which a minimum of two
ACCLPP members served along with several non-ACCLPP consultants. Dr.
Campbell expressed her appreciation of the diligent efforts by Drs.
Matte and Michael Weitzman, the <10 Workgroup Chair, in preparing and
revising the report. Similar to Dr. Lynn, she also believed that the
document is now in a position to be finalized with editing.
Concerning the criticism by some ACCLPP members that the conclusions are
vague or equivocal, Dr. Matte stated that the nature of the workgroup’s
finding reflects uncertainty in the available evidence. For example, the
workgroup was uncertain whether confounding has been fully addressed in
observational and non-experimental studies and noted the need for
additional research in this area.
Dr. Matte concluded his remarks by advising the ACCLPP to decide whether
it agrees with the workgroup’s three major conclusions in voting to
approve the report. First, the weight of evidence shows an association
between BLLs <10 µg/dL and adverse health effects. Second, available
data do not allow definitive conclusion about causation, but the weight
of evidence for the studies favors and does not refute a causal
interpretation. Third, uncertainty in scientific evidence does not point
to a threshold BLL <10 µg/dL above which children should be clinically
defined as “lead poisoned.” Dr. Matte emphasized that the workgroup
would likely not endorse the document if it were modified by the ACCLPP
to state radically different conclusions on these three issues.
Dr. Binns made a motion for ACCLPP to accept and approve the <10
Workgroup reports as an ACCLPP document; Dr. Handy seconded the motion.
Dr. Campbell amended the motion to note that ACCLPP’s approval for the
workgroup report will be provisional based on the following conditions.
The introduction will be reformatted as an executive summary that will
list conclusions in bullet points. A “Statement by ACCLPP” will be added
explaining that the workgroup wrote the report, but ACCLPP reviewed,
provided comments and accepted the document as an ACCLPP product. Both
the executive summary and statement will be distributed to ACCLPP for
review and comment in June or July 2004. Appropriate tables will be
modified to indicate sample size. The report will be submitted to a
medical editor for further refinement and the final document will be
distributed to ACCLPP. With no further discussion, ACCLPP unanimously
approved the <10 Workgroup report with the provisions stated in the
amended motion.
Dr. Helen Binns,
the Workgroup Chair, reported that dual efforts are being made for this
activity. Drs. Brown and Lynn drafted Public Health Implications of
Adverse Health Effects in Children with BLLs <10 µg/dL (the policy
document), while Dr. Binns drafted Understanding Children’s BLL Results:
Information to Aid Decision-Making and Counseling in the Health Care
Setting (the clinical document). Although the two documents are intended
to state ACCLPP’s opinion, readers are also referred to the case
management, primary prevention and <10 Workgroup reports. The policy and
clinical documents have different audiences, but ACCLPP should consider
whether the reports should be maintained separately or combined. Dr.
Binns was in favor of continuing to produce two documents to increase
readership and reach diverse audiences. For example, the policy document
can be published in a public health journal, while the clinical document
can be published in a pediatric journal.
ACCLPP’s recommendations on the workgroup’s policy and clinical
documents are outlined below.
Dr. Brown made follow-up remarks to ACCLPP’s deliberations. First,
CDC has discussed whether a fundamental recommendation should be made
stating that screening children to identify those with BLLs 5-10 µg/dL
will be beneficial to the individual child. CDC has not made this
statement to date and agreement was reached during the previous ACCLPP
meeting not to lower the BLL of concern from 10 µg/dL. However, CDC has
no problem producing a document explaining that jurisdictions are using
local data to monitor lower BLLs and determine if the Intervention will
be effective. Second, CDC notes that efforts in 1991 to target primary
prevention to communities with high rates of children with BLLs >10 µg/dL
were unsuccessful.
Third, LPPB expects to complete the final report on the lead vocabulary
in June 2004. The focus group data will inform the process of clinicians
communicating with parents, but this activity should not delay efforts
to finalize the policy or clinical documents. Fourth, the policy
document does not describe strategies to comply with the recommendations
because this guidance is available in existing well-written reports.
Instead, the policy document references ACCLPP’s primary prevention and
case management documents as well as CDC’s 1991 and 1997 statements on
screening and follow-up of children with EBLLs.
Fifth, Dr. Brown was extremely concerned with ACCLPP’s focus on and use
of the term “5-9” due to the danger of identifying a new group of
children who need and can benefit from individual intervention. Since no
evidence has been collected to date to support this statement, ACCLPP
should use the terms “<10" or “>10.” To address the issue of BLLs 5-9
µg/dL, however, LPPB supports ACCLPP making the following research
statement. Very young children with BLLs 5-9 µg/dL may actually be the
same children whose BLLs are in the process of increasing. Efforts will
be made to rigorously evaluate this trend and determine whether health
education, DLL reduction and other interventions will interrupt the
cycle. Lead is a poison that is not beneficial to the human body and a
safe level of lead does not exist.
Sixth, ACCLPP’s letter to the Centers for Medicare and Medicaid Services
(CMS) on screening waivers was distributed throughout CMS and reviewed,
but new staffs are now involved with this process. Dr. Brown and the new
CMS staff will meet on March 10, 2004 to discuss developing consistent
guidance. However, CMS has already stated in writing its commitment to
creating a waiver process and ensuring screening is performed by
aggressively targeting states that do not submit waivers.
Dr. Hoffman placed the following motion on the floor. The <10 Workgroup
report should be released in conjunction with the policy document as a
collective body of evidence. The policy document should serve as
ACCLPP’s official statement for the <10 Workgroup report. Relevant text
from the clinical document should be incorporated into the policy
document. The clinical document should remain as a separate paper to
reach a specific audience. Dr. Lynn seconded the motion. With no
further discussion, ACCLPP unanimously approved the motion.
Drs. Binns, Brown and Campbell described the process to continue
developing the policy and clinical documents. Drafts will be distributed
to ACCLPP for review by e-mail with a request to submit comments
electronically rather than through conference calls. None of the revised
versions will be labeled or referred to as “final;” instead, dates will
be used to distinguish among drafts. A short abstract will be developed
and incorporated into the clinical document. ACCLPP will submit comments
on the policy document to Dr. Brown by April 15, 2004 and comments on
the clinical document to Dr. Binns by May 15, 2004.
Ms. Conrad
thanked ACCLPP for voting to collectively release the policy document
and <10 Workgroup report because the two documents will serve as
powerful guidance to states.
With no further discussion or business brought before ACCLPP, Dr.
Campbell recessed the meeting at 5:38 p.m. on March 9, 2004.
Dr. Leighton announced that the expert panel has held two meetings,
completed a draft of the literature review and expects to submit a
report of its recommendations in Spring 2004.
Dr. Lynn
requested that ACCLPP place the following item on a future agenda.
Minimal emphasis has been placed on interpreting and responding to EBLLs
in adolescents 8-18 years of age; no guidance has been developed on this
issue to date. EBLLs of 25-35 µg/dL have been identified among persons
in this age range in Alaska who serve on rifle teams and practice
shooting in indoor ranges. Alaska will soon summarize its
investigations, but continues to struggle with providing sound guidance
to clinicians who serve these patients. Dr. Brown confirmed that a
presentation on this issue can be made at a future meeting to determine
whether ACCLPP should take action. She mentioned that NIOSH and other
researchers with expertise in EBLLs among adolescents, police officers
and other groups resulting from rifle ranges can serve as presenters.
Dr. Brown announced that ACCLPP’s charter has been amended to include a
parent of an affected child or a representative of the affected
population as a member. CDC will submit three potential candidates to
the HHS Secretary for consideration, but selection of the new member is
at the discretion of the HHS Secretary. Dr. Keyvan-Larijani recalled
that ACCLPP drafted a letter to the HHS Secretary to ask the Department
of State to adopt lead testing of refugee children entering the United
States. He requested a status report of this activity. Dr. Campbell
mentioned that CDC provided an update on this issue at a previous
meeting and informed the members of efforts to distribute ACCLPP’s
letters to various participating agencies. However, she agreed that
another status report on lead testing of immigrant, refugee and adopted
children entering the United States should be given at a future meeting.
Dr. Ho inquired about ACCLPP’s role in issuing guidance on the
developmental support for children whose BLLs have declined. Dr.
Campbell reported that medical management as well as developmental
assessment and interventions were covered in ACCLPP’s published case
management document. Ms. McLaine noted that despite the case management
recommendations, minimal research has been conducted in the context of
useful educational methodologies and educational treatment. She raised
the possibility of ACCLPP revisiting this issue over the next year to
obtain additional input from outside researchers. Dr. Binns added that
the case management document will not be useful or known to school
personnel. As a result, relevant text from the document should be
extracted and published in the school literature to highlight the key
concepts of lead poisoning for school personnel. Based on these
comments, Dr. Brown confirmed that LPPB will highlight developmental
support for children whose BLLs have declined as an issue to address
over the next two years.
The attendees
joined Dr. Brown in applauding LPPB staff members, Ms. Crystal Gresham,
Ms. Janet Henry and Mr. Penn Jacobs, for their tremendous efforts in
making logistical arrangements for a successful meeting. The next ACCLPP
meeting will be held on October 19-20, 2004. Background materials
distributed to ACCLPP for the meeting are collectively appended to the
minutes in Attachment 1.
With no further discussion or business brought before ACCLPP, Dr.
Campbell adjourned the meeting at 12:06 p.m. on March 10, 2004.
I hereby certify that to the best of my knowledge, the foregoing Minutes of the proceedings are accurate and complete. | |
Date |
Carla C. Campbell, M.D., M.S. ACCLPP Chair |